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Burning Questions and Answers

You’ve come to the right place if you need a crash course in credentialing.

The most searched for terms about physician credentialing on the Internet are: Why credentialing is important for healthcare professionals, how long the process takes and who needs CAQH credentialing.

Given that, we will focus on those three aspects of credentialing in this month’s blog.

1) Why is Credentialing Important?

The process verifies and assesses a physician’s education, training and experience, which also signals to patients – and medical colleagues – they can confidently trust in a physician’s qualifications and clinical care.

Credentialing is a three step process – credentialing, privileging and enrollment – but keep in mind that it is an ongoing process. Physicians must go through the process any time they start or change jobs, establish a medical practice of their own or seek new and expanded privileges. It is a critical step to becoming a practicing physician, and also includes a physician’s enrollment into health plans so they can receive payment for services rendered.

It is in the credentialing phase where all of your demographic information as well as proof of your education and degrees, training, experience and qualifications are assessed and verified.

Once a medical practice evaluates credentials and performance, it is in the privileging stage that the services and procedures a physician is permitted to perform are determined and approved.

In the final credentialing phase working physicians must enroll with desired insurance companies so that they can bill and be paid for approved services and procedures from insurers.

2) How Long Does the Process Take?

Because the process and amount of paperwork and forms required to be filled out can be daunting, physicians should give themselves as long as six months to meet all the requirements, according to the American Medical Association.

It’s a good idea to start gathering and organizing the information and supporting documentation required before you need it as part of an application with a hospital or medical practice. Keeping your information regularly up to date is a best practice and makes the re-credentialing process less arduous.

3) Who Needs CAQH Credentialing?

The Coalition for Affordable Quality Healthcare (CAQH) is not a mandatory or official part of credentialing or re-credentialing, but it sure can make it easier for physicians. This coalition began its uniform credentialing program about 15 years ago, which has been adopted by most insurers and payers in the United States.

After submitting the initial CAQH application, be prepared to re-attest four times annually that your information is correct so that you maintain continuous insurance eligibility. Completing the initial CAQH ProView profile may take up to two hours, but ongoing maintenance is easy.

And remember, credentialing is an ongoing process for both individual physicians and medical practices and institutions. Individual physicians must ensure their professional information is complete and current at all times; medical practices and institutions must ensure privileges are intact and enrollments with insurers and payers are up to date in order to get paid and maintain healthy cash flow.

For a deeper dive into the process of credentialing and detailed how-to steps, read this month’s guide

Credentialing: Tips and Tricks to Prepare and Streamline the Process

Credentialing Tips & Tracks